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U IFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - INSTALLATION <br /> CERTIFICATE OF COMPLIANCE <br /> (One page per tank) <br /> Page_of_ <br /> I.FACILITY IDENTIFICATION <br /> BUSINESS NAME(Same as FACILM NAME or DBA—Doing Business As) 3. <br /> ADDRESS(For local use only) 476. <br /> FACILITY ID# L TANK 11)# 477. <br /> II.INSTALLATION <br /> (Check all that apply) <br /> 478, <br /> The installer has been trained and certified by the tank and piping manufacturers. <br /> The installation has been inspected and certified by a registered professional engineer having education and experience 479. <br /> with underground storage tank installations. <br /> Oso. <br /> The installation has been inspected and approved by the Unified Program Agency. <br /> asl. <br /> All work listed on the manufacturer's installation checklist has been completed. <br /> ase. <br /> The installer has been certified or licensed by the Contractors' State License Board. <br /> [� The underground storage tank, any primary piping, and secondary containment was installed according to applicable 483. <br /> voluntary consensus standards and written manufacturer's installation procedures. <br /> Description of work being certified: <br /> M.TANK OWNER/AGENT SIGNATURE <br /> I certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNATbMANK OWNER/AGENT DATE 484. <br /> -q-o8 <br /> NAMEK OWNER/AGENT(print) 485. TITLE OF TANK OWNER/AGENT ash. <br /> UPCF(1/99)Hwfwrc-c-1/2 www.unidocs.org Rev.02/16/00 <br />